355Rev. bioét. (Impr.). 2016; 24 (2): 355-67http://dx.doi.org/10.1590/1983-80422016242136

Euthanasia and assisted suicide in western countries: a systematic reviewMariana Parreiras Reis de Castro 1, Guilherme Cafure Antunes 2, Lívia Maria Pacelli Marcon 3, Lucas Silva Andrade 4, Sarah Rückl 5, Vera Lúcia Ângelo Andrade 6

AbstractIn 2015 the issue of assisted death was widely publicized by the international media after the first legal eu-thanasia case was held in Colombia. Also in this same year, assisted suicide was legalized in Canada and in the state of California in the United States. Currently, assisted death is allowed in four Western European coun-tries: Netherlands, Belgium, Luxembourg and Switzerland; two North American countries: Canada and the US, in the states of Oregon, Washington, Montana, Vermont and California; and Colombia, the sole represen-tative in South America. From a systematic literature review, this work aims to establish the prevalence and the criteria adopted for the practice of euthanasia and assisted suicide in western countries and to discuss the position of similar countries where this practice is not recognized. A better understanding of the subject appears to be critical to the formation of opinions and the encouragement of further discussions.Keywords: Assisted death. Euthanasia. Assisted suicide. Palliative care.

ResumoEutanásia e suicídio assistido em países ocidentais: revisão sistemáticaEm 2015 a temática da morte assistida foi amplamente divulgada pela mídia após o primeiro caso legal de eutanásia ter sido realizado na Colômbia. Além disso, no mesmo ano, o suicídio assistido foi legalizado no Canadá e no estado da Califórnia, nos Estados Unidos. Atualmente, a morte assistida é permitida em quatro países da Europa Ocidental: Holanda, Bélgica, Luxemburgo e Suíça; em dois países norte-americanos: Canadá e Estados Unidos, nos estados de Oregon, Washington, Montana, Vermont e Califórnia; e na Colômbia, único representante da América do Sul. A partir de revisão sistemática da literatura, objetivou-se estabelecer a prevalência e os critérios adotados para a prática da eutanásia e do suicídio assistido em países ocidentais e discutir a posição de países onde essa prática não é reconhecida. Uma melhor compreensão do assunto mostra-se fundamental para a formação de opiniões e fomento de futuros debates.Palavras-chave: Morte assistida. Eutanásia. Suicídio assistido. Cuidado paliativo.

Resumen Eutanasia y suicidio asistido en países occidentales: una revisión sistemáticaEn 2015, el tema de la muerte asistida fue ampliamente difundida por los medios del mundo después de que el primer caso de la eutanasia legal haya sido realizado en Colombia. También, ese año el suicidio asistido fue legalizado en Canadá y en el estado de California en Estados Unidos. Actualmente, el suicidio asistido está permitido en cuatro países de Europa occidental: Países Bajos, Bélgica, Luxemburgo y Suiza; dos países de América del Norte: Canadá y Estados Unidos, en el estado de Oregon, Washington, Montana, Vermont y California; y Colombia, único representante de América del Sur. A partir de una revisión sistemática de la literatura, se planteo como objetivo determinar la prevalencia y los criterios adoptados para la práctica de la eutanasia y el suicidio asistido en los países occidentales y discutir la posición de países similares donde no se reconoce esta práctica. Una mejor comprensión de la materia parece ser crítica para la formación de opinio-nes y el fomento de las futuras discusiones.Palabras clave: Muerte asistida. Eutanasia. Suicidio asistido. Cuidado paliativo.

1. Graduanda marianaprc@hotmail.com – Universidade José do Rosário Vellano (Unifenas), Belo Horizonte/MG 2. Graduando gc_antunes@hotmail.com – (Unifenas), Belo Horizonte/MG 3. Graduanda liviampacellim@gmail.com – (Unifenas), Belo Horizonte/MG 4. Graduando lucassilva92@hotmail.com – (Unifenas), Belo Horizonte/MG 5. Doutora sarahruckl@gmail.com – Universidade de Heidelberg, Heidelberg, Alemanha 6. Doutora vera.angelo@unifenas.br – Universidade Federal de Minas Gerais, Belo Horizonte/MG, Brasil.

CorrespondênciaLívia Maria Pacelli Marcon – Rua Aimorés, 2165, apt 301 Bairro Lourdes CEP 30140-072. Belo Horizonte/MG, Brasil.

Declaram não haver conflitos de interesse.

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Historically, the word euthanasia means “good death”, in other words, death without pain, with-out suffering. In the twentieth century, during the Third Reich, the word gained a negative connotation when it was improperly used in Nazi policies aimed at eliminating lives that were considered not worthy to exist 1. Subsequently, after the word was demy-stified, discussions on the topic resurfaced, and, currently, the practice of euthanasia, in its classic sense, is allowed in some countries. In a more con-temporary definition, euthanasia can be understood as employment or abstention of procedures that al-low accelerating or inducing the death of incurably ill patients, in order to free them from the extreme suffering that torments them 1.

As for the patient’s consent, euthanasia can be classified into non-voluntary and voluntary – the first takes place without knowing the will of the pa-tient, and the second in response to the expressed wishes of the patient 1. The latter differs from assist-ed suicide as it is performed by a physician, while in assisted suicide the patient is the one who performs the final action.

Both from the medical and from the legal point of views, there is a big difference between “killing” and “letting die” 2. Therefore, regarding the act, euthanasia is divided into active and passive, the first of which denotes the deliberate act of induc-ing death without the patient suffering (using, for example, lethal injection), and the second refers to death by deliberate omission to start medical action that would guarantee the prolongation of survival. It is worth noting the vagueness of the distinction between passive euthanasia and orthothanasia, which refers to “death at the right time”, since there is no real boundaries between” not intervening and simply letting die” and “letting die in the seemingly correct time” 1.

The term “assisted death” or “assisted dy-ing” encompasses both the concept of euthanasia and assisted suicide 2, both subjects of ongoing de-bates in today’s society. Four European, one South American and two North Americans countries have legalized euthanasia and/or assisted suicide, but the law of these countries differ considerably regarding the practices 3.

In July 2015, the topic was widely reported by the media after the first legal case of euthana-sia was performed in Colombia 4. In the same year, assisted suicide was legalized in Canada and in the state of California, in the United States (US) 4. Given the divergent views and the general interest of the community on the subject, having knowledge of the

experience and the views of various countries re-garding the issue is essential to form opinions 3. This is still a very controversial debate and - regardless of political, religious or moral aspects– it is funda-mentally a human issue 2. Thus, the objective of this work is to establish the prevalence and the criteria adopted for the practice of euthanasia and assisted suicide in Western countries and to discuss the po-sition of other countries where the practice is not recognized.

Method

This work consists of a systematic review of the literature. The words “euthanasia,” “assisted suicide”, “Netherlands”, “Belgium”, “Luxembourg”, “Switzerland”, “United Kingdom”, “Brazil”, “Co-lombia” “Canada” and “United States” were used, in English and Portuguese, as keywords for the re-search. To identify the publications that composed this study, an online search was done in the follow-ing databases: Scientific Electronic Library Online (SciELO), National Center for Biotechnology Infor-mation (PubMed) and Google Scholar. The MeSH tool was used to help the search and categorization of articles.

The research was based on 19 publications relevant to the topic investigated. A list with these publications is presented at the end in Appendix 1. The following previously established inclusion cri-teria were considered: original works or reviews, available in full, published between 2005 and 2015. The articles that did not fit the inclusion criteria were removed from the sample. Regarding the ex-clusion criteria, we considered duplicated articles, publications prior to 2005 and those that, despite having the selected descriptors, did not directly ad-dress the proposed topic. In addition, recent news articles, websites and official reports from the coun-tries mentioned were consulted to update data. Moreover, some articles were suggested by experts.

Method and results

The selection of items for systematic review was done according to the flow chart (Figure 1). Based on these publications, Table 1 briefly de-scribes information regarding the journal, author, year of publication, article title, type of study, objective and limitations presented by the publica-tions studied.

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DatabasesPubmed, SciELO, Google Scholar

Criteria for inclusion- Articles available in full- Published between 2005 and 2015- Original or review

Criteria for exclusion- Duplicity in articles- Publication prior to 2005- Did not directly address the proposed theme: exclusion made through the title and the summary

KeywordsEuthanasia, assisted suicide,

Brazil, Colombia, Canada, United States, Belgium, Luxembourg,

Switzerland and United Kingdom

Articles selected: 422

Articles selected: 15

Articles used: 19

Total referencess: 49

Articles recommendedby experts: 4

* Other sources- Official sites of the countries surveyed- Official reports, documents and database- Recent newspaper articles

Figure 1. Selection of studies

Discussion

Assisted death is allowed in four Western European countries: the Netherlands, Belgium, Luxembourg and Switzerland; two North American countries: Canada and the United States, in the states of Oregon, Washington, Montana and Ver-mont; and in South America: in Colombia 4. The laws and criteria adopted for the purposes of this prac-tice differ in each country. Explaining how assisted death occurs in these locations and compare their legislation to that of other similar countries in so-cio-economic and cultural aspects allows a better understanding of the subject, and works as a basis for future discussions 2. The situation in Brazil and the UK has been addressed at the end of this paper in order to compare the position of other countries and enrich the discussion. The timeline with key milestones regarding assisted death in the world is presented in Appendix 2 to facilitate understanding.

ColombiaColombia is the only country in Latin Ameri-

ca where euthanasia is permitted. Although it was

decriminalized in 1997 by the Constitutional Court, only in April 2015 the Ministério da Saúde (Minis-try of Health) defined how it might occur. Until that date, it was classified as “murder by compassion” according to Article 326 of the Criminal Code, and the lack of well-established criteria for its realiza-tion, coupled with the controversial legislation, generated ambiguity, conflicting interpretations and uncertainties regarding the matter 4,5.

Currently, the practice is regulated by Reso-lution 12116/2015 from the Ministério da Saúde e Proteção Social (Ministry of Health and Social Protection), which establishes criteria and proce-dures to ensure the right to death with dignity 6,7. Intravenous drugs can be administered by physi-cians, in hospitals, to adult patients with terminal diseases that cause intense pain and suffering that cannot be relieved. The patient must consciously request assisted death, which must be authorized and supervised by a specialist doctor, a lawyer, and a psychiatrist or psychologist. Moreover, the current legislation does not prohibit this procedure for for-eign patients 4.

Only one case of euthanasia has been re-ported so far in the country, on the 3rd July 2015.

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It was Ovídio Gonzáles (79) who was stricken by a rare facial cancer that, although not metastasized, caused intense chronic pain 4. Therefore, in view of the recent legalization, it is necessary to invest in the training of physicians and health professionals to deal with end of life ethical dilemmas 5,8.

United StatesAssisted suicide is legal in five of the fifty US

states: Oregon, Washington, Montana, Vermont and California 4,9. In 2014, New Mexico passed legislation consistent with the practice, but the decision was reversed on appeal in August 2015 4. On the other hand, euthanasia is banned in all states 2.

The first state to legalize assisted suicide was Oregon, on the 27th October 1997, with the approval of the “Death with Dignity Act” 10, which allows com-petent (able to consciously express their will) adults (from the age of 18), residents in Oregon, with ter-minal illnesses and life expectancy of less than six months, to receive medications in lethal doses, through voluntary self-administration, expressly prescribed by a doctor for this purpose. According to the Act, the self-administration of these lethal drugs is not considered suicide, but death with dignity 3,11. It is worth noting that many Catholic hospitals have opted out from this practice 4.

Since the law was passed in 1997 until the end of 2014, 1,327 people received the prescrip-tion of lethal medication, and of those, 859 died after self-administration. Six people woke up after the procedure, and most died within days. Some pa-tients for whom the medication was prescribed died before administration, others waited to receive it, and some cases were not properly notified 12.

Of the 859 people who received lethal medi-cation, 52.7% were men, predominantly in the age group between 65 and 74, with higher education or post-graduation degree (45.9%). In 78% of the cas-es, the disease was cancer, followed by amyotrophic lateral sclerosis (ALS) at 8.3%. Most patients died at home (94.6%) and received palliative care. The most common concerns of these patients were loss of au-tonomy, mentioned by 91.5% of them, loss of ability to participate in activities that make life enjoyable (88.7%) and loss of dignity (79.3%) 12.

In March 2009, the State of Washington ap-proved its “Death with Dignity Act”, almost identical to the one from Oregon, by which competent adults living in the area, with a life expectancy of six months or less, may require self-administration of a lethal medication prescribed by a doctor 3,4,13. From 2009

to 2014, 724 people received prescriptions for lethal medication, of these, 712 died after self-adminis-tration. The situation of patients who received the prescriptions but did not use them is unknown 13. As in Oregon, the statistics show, among the deaths, a higher incidence of men between 65 and 74 of age, with high education. The predominant underlying disease was also cancer, followed by neurodegener-ative diseases 13.

In the state of Montana, the Supreme Court ruled on the 31st December 2009, that assisted sui-cide was not illegal, after the case of the patient Robert Baxter, a 76 year-old retired truck driver, carrying a terminal form of lymphocytic leuke-mia 14. Unlike other states, Montana law is not as well-regulated on the subject. According to the Supreme Court, patients should be adults, men-tally competent and suffer from terminal illnesses to request lethal medication. The act is secured by rights of privacy and dignity established by the constitution, and the doctors who assist are also protected by law 3,14,15.

In Vermont, assisted suicide was legalized on the 20th May 2013 by Act 39 – regarding “patient choice and control at end of life”. The Departamen-to de Saúde estadual (state Department of Health) suggested that by 2016, physicians and patients were gradually adhering to the proposal of the Act, since many hospitals opted out, stating they were not ready to implement it. In any case, the right to assisted death is reserved for adult patients, resi-dents of Vermont, with life expectancy shorter than six months, who are able to voluntarily request and self-administer the medication dose 4,16.

On the 5th October 2015, Jerry Brown, gover-nor of California, signed the Assembly Bill No. 15, also referred to as the “End of Life Option Act”, allowing assisted suicide for competent adults, res-idents in the state, with terminal illnesses and life expectancy of less than six months 17. The law, which came into force in 2016, was based on the Act from Oregon, from 1997. Its approval resumed old discus-sions about assisted death 18,19. At the time the law was passed, the governor stated that, in the end, he was led to reflect on how he would act in the face of his own death. The governor declared that he would not know what to do if he was dying with prolonged and excruciating pain. Also, he pointed out that it was comforting to be able to consider the options offered by the Oregon Act and would not deny that right to others

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CanadaIn February 2015, after six years of debate in the

Supreme Court, with the cases of patients Kay Car-ter and Gloria Taylor, Canada suspended the ban on euthanasia and assisted suicide 4, 20-22. A grace period of one year was established, during which the feder-al and provincial government of Canada, as well as health professionals, were to prepare themselves to implement the new law. In January 2016, the deadline was extended for four months, extending the official legalization of assisted death and the deadline for provincial governments to establish their guidelines to the 6th June. If this does not happen, the activity is going to be legal in the country, but not regulated in certain provinces, which will give physicians freedom to modify their own behaviour. Moreover, by that date, in un-regulated territories, aid to assisted death can be obtained through legal concessions 22-24.

Quebec was the first province to regulate assisted death through the “Act Respecting End-of-Life Care”, which entered into force in December 2015. Approved in the previous year, and based on Oregon’s legislation, the Act covers capable adults who were diagnosed with serious and incurable diseases, advanced and irreversible decline of their capabilities, and intense physical and psychological suffering. However, it does not require a maximum life expectancy of six months 4,24,25. According to the Act, “medical aid in dying” is the administration by a physician, of a lethal substance, following the patient’s request 25. This practice characterizes ac-tive voluntary euthanasia, although the term is not used explicitly in the document. The Canadian me-dia announced in January 2016 that the first case of assisted death was confirmed by health authorities in Quebec, which did not provide information about the procedure and the patient’s profile 26,27.

The other Canadian territories have also mobi-lized themselves for the regulation of assisted death. In November 2015, a group created by the provin-cial government issued an advisory report to the provinces, aiming to draw up their own guidelines 28.

In January 2016, the College of Physicians and Surgeons of Ontario published the “Interim Guidance on Physician-Assisted Death”, regulating euthanasia and assisted suicide, with criteria similar to those adopted by Quebec 22. In the same month, in a press article 29, a lawyer from the Canadian Justice De-partment expressed his concerns regarding the new changes. According to him, the country will face a major challenge in the management of issues relat-ed to assisted death, as the country’s health policies are regulated by provincial laws, while criminal laws

are under national jurisdiction. To avoid problems, authorities suggested unified national guidelines, despite the short time to regulate 29.

The NetherlandsIn April 2002, both euthanasia and the assisted

suicide were regulated and became no longer pun-ishable in the Netherlands, after more than thirty years of debate. Before legalization, these practices were tolerated for a few decades, having been re-ported by Dutch doctors since 1991 3,4,30.

The process of assisted death should fit into several criteria very similar to those applied in Bel-gium and Luxembourg. In all three countries, the patient must be competent, carry out the request voluntarily, and have chronic conditions that cause intense physical or psychological suffering. The phy-sician should inform the patient about his or her health status and life expectancy and, together, reach the conclusion that there is no reasonable al-ternative. Also, another doctor should be consulted about the case, and all procedures should be report-ed to the authorities 3,4,30.

People with dementia are also eligible, as well as children, aged between 12 and 17, with proven mental capacity. Parents or guardians must also agree to act in the case of patients between 12 and 15 years old, and join the discussions for patients between 16 and 17 years old. In some spe-cific circumstances, assisted death may also apply to newborns, according to the regulations of the “Groningen Protocol”, from 2005 4,31.

Between September 2002 and December 2007, 10,319 cases were reported. Of these, 54% were male, 53% were between 60 and 79 years old and 87% were diagnosed with cancer 30. In 2013, 4,829 cases were reported, and 78.5% of these oc-curred at home. In recent years, five doctors (0.1% of cases) were judged for not fulfilling the criteria set out in the legislation 4,30.

BelgiumSince September 2002, voluntary euthanasia

has been allowed in Belgium for mentally compe-tent people, suffering from incurable conditions, including mental illness, which cause unbearable physical or psychological suffering. The assisted suicide is not explicitly regulated by law, but cas-es reported to the Comissão Federal de Controle e Avaliação de Eutanásia (Federal Evaluation and Control Commission for Euthanasia) are treated the same as euthanasia 3,4.

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The Belgian legislation is similar to the Dutch one, however, if the patient is not terminal, the doctor should consult an independent third par-ty specialist, and at least one month should pass between the patient’s request and the euthanasia procedure 3,30.

On the 13th February 2014, Belgium removed the age restriction for euthanasia, despite strong opposition from religious people and from some members of the medical profession. Before this change, the legislation of euthanasia already applied to adolescents over 15 years old, legally emancipat-ed by legal decree. In any case, in the last twelve years, the Federal Commission reported only four cases involving patients younger than 20, and none of them was a child 32.

With the new legislation, children of any age may require euthanasia, provided they are able to understand the consequences of their decisions, as certified by a child psychologist or psychiatrist. The child must be in terminal condition, with constant and unbearable physical suffering, which cannot be relieved. The child’s decision should be supported by their parents or legal guardians, who have veto rights 31. Although the age restriction is not imposed by law, the child must show discernment capacity and be conscious at the time of making the request. These prerequisites limit the range of children who might qualify, and the forecast is that the changes, although very important, will not have such a signif-icant impact 31.

According to the Federal Commission between 2010 and 2014, reported cases almost doubled, in-creasing from 953 to 1,807. The prevalence remains men, aged between 60 and 79, with cancer; howev-er, a recent study showed increased requests from patients older than 80 and with other diseases. Furthermore, it is estimated that 44% of assisted deaths occur in hospitals, 43% at home and 11% in nursing homes 4,30,32.

LuxembourgOn the 16th March 2009, euthanasia and as-

sisted suicide were legalized in Luxembourg, and are currently regulated by the Comissão Nacional de Controle e Avaliação (National Commission for Control and Assessment). The law covers competent adults, people with incurable and terminal diseases that cause physical or psychological constant and unbearable suffering, with no possibility of relief 4, 34.

The patient must request the procedure through his or her “end-of-life provisions”, which is a

written document that is obligatorily registered and analysed by the Comissão Nacional de Controle e Avaliação (National Commission for Control and As-sessment). The document also allows the patient to record the circumstances in which he or she would like to be submit to assisted death, which is per-formed by a physician who the applicant trusts. The request may be revoked by the patient at any time, and in this case will be removed from the medical record 34. Before the procedure, the physician should consult another independent expert, the patient’s health team, and a “trusted person” appointed by the patient; after its completion, the death must be reported to the Commission within eight days 4,34.

According to the Commission’s last report, between 2009 and 2014, 34 cases of assisted death had been registered. Of these, 21 were female, pre-dominantly aged between 60 and 79; 27 had cancer and 22 underwent the procedure in a hospital 35.

SwitzerlandAssisted suicide is permitted in Switzerland

and, in accordance with Article 115 of the Códi-go Penal (Penal Code) of 1918, the practice is only punishable when performed for “non-altruistic” reasons 3,4. Unlike other countries, such as the Neth-erlands, and some US states, assisted suicide is not clearly regulated, and there are no specific laws that determine under what conditions a person can re-quest assistance 36.

Although Article 115 was not originally devel-oped for the regulation of this practice, from the 1980s onwards many institutions who support as-sisted death used it as a basis to justify their actions. Currently, six active institutions are responsible for most cases of assisted suicide in the country, with different criteria for selecting candidates 3, 36.

Only three institutions restrict the procedure for terminally ill patients, and in four of them for-eigners can also undertake the procedure. It is estimated that between 2008 and 2012, 611 for-eigners, including a Brazilian, 268 from Germany and 126 from the UK, received lethal medication. During this period, foreigners accounted for almost two-thirds of all cases 4,36. The service has attracted a considerable number of patients, called “suicide tourists”, to the country. In the UK, for example, the term “going to Switzerland” has become a euphe-mism for assisted suicide 36.

The procedure is also allowed for people with mental illness, but the Supreme Court requires a psychiatric report stating that the patient’s suicide

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desire was self-determined and well considered, and is not part of their mental disorder 3.

Doctors who prescribe the drug are respon-sible for the process and should always inform patients about their condition and possible alter-natives. However, a well-established doctor-patient relationship is not prerequisite for practice, and usually these doctors are not present at the time of death 3.

All countries, except Switzerland and the state of Montana (US) require notification of cases of as-sisted suicide and regular release of public reports 3. However, recent studies show that the user’s profile differs from other countries: assistance is predomi-nant amongst women, and the percentage of cancer patients is lower 3, 35. Euthanasia is prohibited in Switzerland in accordance with Article 114 of the Código Penal (Penal Code) 3.

BrazilAlthough not yet regulated in Brazil, the topic

has been widely discussed among physicians, phi-losophers, religious people and legal professionals who seek the best way to insert the issue in our legal system 37. Euthanasia is considered a crime of murder, according to the Article 121 of the Código Penal (Criminal Code), and, depending on the cir-cumstances, the conduct of the agent can also be configured as a crime of inducement, instigation or assistance to suicide, as stated in Article 122 38. Fur-thermore, in accordance with Article 41 of the sixth Código de Ética Médica (Code of Medical Ethics), it is forbidden for physicians to shorten the patient’s life, even if upon their request or that of their le-gal representative. The Code also points out that, in cases of incurable and terminal illness, the physi-cian should offer all palliative care available without undertaking useless or obstinate diagnostic or ther-apeutic actions 39, 40.

It is noteworthy that, as claimed by Felix, Cos-ta, Alves Andrade, Duarte and Brito, orthothanasia (sometimes used as a synonym for “passive eutha-nasia”) is well secured by the Constitution, as it aims to ensure a dignified death for the terminal patient, who has the autonomy to refuse inhuman and de-grading treatment 37.

The Conselho Federal de Medicina (Fed-eral Council of Medicine) also made its position clear on the subject. Resolution 1805/2006 allows the physician to limit or suspend procedures and treatments that prolong the life of terminally ill patients, respecting the will of the person or their

legal representative. It also ensures that the patient continues to receive all the care necessary to relieve suffering, assuring them comfort, comprehensive care and right to be discharged 40, 41. Resolution 1995/2012, valuing the principle of patient autono-my, provides for an advance directive (or living will), ensuring its prevalence over any other non-medi-cal opinion, including the wishes of the family. The directives are defined by the resolution as a set of desires, previously and expressly manifested by the patient, regarding the care and treatment they want, or do not want, to receive when they are unable to freely and autonomously express their will 40,42.

United KingdomThe UK does not officially allow assisted death,

although in recent years discussions on the subject have been very frequent 43. Recent research shows that the majority of the population, including much of the medical profession, is in favour of assisted suicide 43. However, in the last decade, the British Parliament rejected several proposals for its regu-lation 2. The last of them, the “Assisted Dying Bill”, prepared by Lord Falconer, was rejected by the lower house in September 2015 44. The document, based on the Oregon legislation, proposed the le-galisation of assisted suicide (but not of euthanasia) for competent patients, over 18 years old, with a life expectancy of less than six months 43,45.

Active euthanasia is considered a crime of murder, and according to section 2 of the Suicide Act 1961, assisting it is punishable by up to 14 years in prison 2,46. However, in February 2010, the Crown Prosecution Service introduced new guidelines on assisted suicide, after the case of Debbie Purdy. She was diagnosed with multiple sclerosis in 1994, and wanted to know if her husband would be charged if he accompanied her to Switzerland to receive lethal medication. The new guidelines state that assisting a suicide may, in some cases, be decriminalized, for example, if the assistance is out of compassion, and the decision of death is voluntary, conscious, well thought out and communicated to the author-ities 2,47. Even after this resolution, legal conflicts continue to occur. In 2013, for example, the wife and the son of a man were arrested for trying to take him to a clinic of assisted death in Switzerland 42.

Final considerations

With the increase in population life expectan-cy, the cases of chronic and disabling diseases also

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increase. Added to this, a stronger focus on human-ized medicine and palliative care prompted debates on quality of death in many countries. In this sce-nario, assisted death is a current, and still very controversial, topic.

In the Western World, euthanasia and/or as-sisted suicide are legal in some countries. Although the criteria adopted for these practices are different in each location, the profile of patients who seek as-sistance is almost invariably the same.

In Brazil, assisted death is not legalized, but the debate is timely, among other reasons, due to the anticipated growth of the elderly population in the coming years, which will also increase the num-ber of chronic and disabling diseases. It is estimated that in 2020 the country will be the sixth largest in the number of elderly 48. This data is worrying, since the quality of death in Brazil is considered poor and undeveloped 48,49. Therefore, we consider that im-provements in terminal patient care are imperative, regardless of the debate in question.

The UK also criminalizes assisted death. However, in recent years, discussions on the subject have become increasingly frequent. The British Parliament refused various legalization proposals, although surveys indicate that the ma-jority of the population is in favour of change. Still, unlike Brazil, the UK leads the ranking of the most

developed countries in the care of patients at the end of life and is considered a world reference in palliative care 48,49.

During the writing of this paper, the first case of euthanasia in Colombia took place, assisted sui-cide was recognized in Canada and in the state of California in the United States, and the state of New Mexico repealed the decision of legalization. That said, we suggest updated research be done at reg-ular intervals.

The issue of assisted death is broad and mul-tifaceted; therefore, the analysis of the data from the countries presented should consider the con-text in which they are, valuing historical, religious, socioeconomic and cultural aspects. Moreover, the discussion raises awareness regarding human finitude, making room for the timely and favour-able development of palliative care services, and stimulating consideration of important bioethical issues such as the right to death and the patient’s autonomy; the sacredness of life; the doctor-pa-tient relationship; the principles of beneficence and non-maleficence; and issues related to the regula-tion of the practice itself.

Finally, we hope that this review represents an updated source of assisted death scenario in the Western World, allowing for more comprehensive and critical view on the subject.

The authors are grateful to the Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPQ (Natio-nal Council for Scientific and Technological Development) for the financial support given and for the PhD grant provided to the co-author Sarah Rückl.

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Participation of the authorsAll authors contributed in the research of the subject, and writing and revising of the article.

Recebido: 14.1.2016

Revisado: 31.5.2016

Aprovado: 13.6.2016

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Euthanasia and assisted suicide in western countries: a systematic review

http://dx.doi.org/10.1590/1983-80422016242136

Journal; author(s); year; country Title Type of

study Objective Limitations

The New England Journal of Medicine; Loggers ET; 2013; England

Implementing a Death with Dignity Program at a comprehensive cancer center

Review Describe the implementation of the “Death with Dignity Program” at the Seattle Cancer Care Alliance

Not informed

International Journal of Law and Psychiatry; Schafer A; 2013; Canada

Physician assisted suicide: the great Canadian euthanasia debate

Review Provide critical arguments and describe the outlines of the current Canadian debate. Legal and ethical issues are raised with respect to physician assisted suicide

Not informed

The New England Journal of Medicine; Attaran A, Phil D; 2015; England

Unanimity on death with dignity – Legalizing physician-assisted dying in Canada

Review Discuss the morality and legalization of assisted suicide, according to the Canadian Constitution

Not informed.

Palliative medicine; Rurup ML, Smets T, Cohen J, Bilsen J, Onwuteaka-Philipsen BD, Deliens L; 2012; England

The first five years of euthanasia legislation in Belgium and the Netherlands: description and comparison of cases

Descriptive and comparative study

Describe and compare the reported cases of euthanasia and physician-assisted suicide in the first five years of legislation

Only reported cases were analyzed. In the Netherlands, most cases (about 80%) are reported, whereas in Belgium only about 53%

JAMA Internal Medicine; Dierickx S, Deliens L, Cohen J, Chambaere K; 2015; Belgium

Comparison of the expression and grantingof requests for euthanasia in Belgium in 2007 vs 2013

Cross-sectional study

Compare the prevalence and granting of euthanasia requests in Belgium in 2007 and 2013

Not informed

Seminars in Fetal & Neonatal Medicine; Vizcarrondo FE; 2014; Netherlands

Neonatal euthanasia: The Groningen Protocol

Review Discuss neonatal euthanasia Not informed

Diversity and Equality in Health and Care; Samanta J; 2015; England

Children and euthanasia: Belgium’s controversial new law

Review Analyze the laws and the history of euthanasia in children worldwide, with a focus on Belgium

Not informed

Journal of Medical Ethics; Gauthier S et al.; 2015; England

Suicide tourism: a pilot study on the Swiss phenomenon

Review Detail assisted suicide, discover the origin of suicide tourists and compare the results with those of previous studies in Zurich

Not informed

Philosophy, Ethics, and Humanities in Medicine; Frost TDG, Sinha D, Gilbert BJ; 2014; England

Should assisted dying be legalized?

Review Describe the impact of assisted suicide on the patient, the doctor and society, and the potential need for this practice within the current medicolegal structure

Not informed

Medicine, Science and the Law; Simillis C; 2008; England

Euthanasia: a summary of the law in England and Wales

Review Analyze the law in England and Wales regarding the different categories of euthanasia

Not informed

Table 1. Characteristics of selected articles [continuation]

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Appendix 2

Figure 2. Timeline

1980 1990 2000 2010 2015

Since the 1980sSwitzerland: Emergence of the first ins�tu�ons for assisted death

May 2013USA (Vermont):Legaliza�on of assisted suicide

February 2014Belgium: Removal of age restric�on for the prac�ce of euthanasia

January 2016Canada (Quebec): The first case of assisted case occurs

June 2016Canada: Deadline for the regula�on of assisted death in the provinces

February 2015Canada: Legaliza�on of assisted suicide and ac�ve voluntary euthanasia

April 2015Colombia: Legaliza�on of euthanasia

July 2015Colombia: The first euthanasia occurs

March 2009Luxemburg: Legaliza�on of euthanasia and assisted suicide

September 2015United Kingdom: Rejec�on of the “Assisted Dying Bill”, which proposed the legaliza�on

October 2015USA (California): Legaliza�on of assisted suicide (“End of Life Op�on Act”)

September 2002Belgium: Legaliza�on of euthanasia

April 2002The Netherlands: Legaliza�on of euthanasia and of assisted suicide (prac�ces that have already been tolerated for a few decades)

March 2009USA (Washington): Legaliza�on of assisted suicide (“Death with Dignity Act”)

December 2009USA (Montana): Decriminaliza�on of assisted suicide

1997Colombia: Decriminaliza�on of euthanasia (which is consid-ered as “murder for mercy”)

October 1997USA - Oregon: Legaliza�on of assisted suicide (Approval of the “Death with Dignity Act”)

December 2015Canada (Quebec): Regula�on of assisted death(“Act Respec�ng End-of-Life Care”)

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Euthanasia and assisted suicide in western countries: a systematic review

http://dx.doi.org/10.1590/1983-80422016242136

Appendix 1

Table 1. Characteristics of selected articlesJournal; author(s); year; country Title Type of

study Objective Limitations

Cadernos de Saúde Pública; Siqueira-Batista R, Schramm FR; 2005; Brazil

Conversações sobre a “boa morte”: o debate bioético acerca da eutanásia[Conversations about “good death”: the bioethical debate on euthanasia]

Review Discuss the morality of euthanasia, properly demarcating the concepts and stressing arguments for and against its realization

Not informed

Singapore Medical Journal; Menon S; 2013; Singapore

Euthanasia: a matter of life or death?

Review Discuss the acceleration of death and the practices of assisted suicide and voluntary euthanasia

The author is biased in his position against euthanasia

Medical Care; Steck N, Egger M, Maessen M, Reisch T, Zwahlen M; 2013; United States

Euthanasia and assisted suicide in selected European countries and US States

Systematic review

Examine numbers, characteristics and trends over time in assisted death in regions where the practice is legal: Belgium, Luxembourg, Netherlands, Switzerland, Oregon, Washington and Montana

Not informed

British Medical Journal; Dyer O, White C, Rada AG; 2015; England

Assisted dying: law and practice around the world

Review Review the practice and the legislation regarding euthanasia in Western Europe and America

Not informed

Ciência e Saúde Coletiva; Felix ZC, Costa SFG, Alves AMPM, Andrade CG, Duarte MCS, Brito FM; 2013; Brazil

Eutanásia, dista-násia e orto-tanásia: revisão integrativa da literatura[Euthanasia, dysthanasia and orthothanasia: integrative literature review]

Review Characterize the scientific output, at a national level, regarding euthanasia, futility and orthothanasia

Not informed

Revista Bioética; Santos DA, Almeida ERP, Silva FF, Andrade LHC, Azevêdo LA, Neves NMBC; 2014; Brazil

Reflexões bioéticas sobre a eutanásia a partir de caso paradigmático[Bioethical reflections on euthanasia based on a paradigmatic case]

Reflective review

Analyze aspects of the process of dying: euthanasia and orthothanasia, and its relationship to the bioethical principle of autonomy

Not informed

Revista Latino Americana de Bioética; Guerra YM; 2013; Colombia

Ley, jurisprudencia y eutanasia: introducción al estudio de la normatividad comparada a la luz del caso colombiano[Law, jurisprudence and euthanasia: introduction to the study of comparative regulations in light of the Colombian case]

Comparative analysis

Analyze the laws and the history of euthanasia in Colombia to clarify legal and bioethical issues on the topic

Outdated data: the legislation has changed after the publication of the article

Colombia Médica; Torres JHR; 2015; Colombia

The right to die with dignity and conscientious objection

Review Assess patients’ right of death according to the Constitution

Not informed

Revista de Salud Pública; Sarmiento-Medina MI et al.; 2012; Colombia

Problemas y decisiones al final de la vida en pacientes con enfermedad en etapa terminal[Problems and decisions at the end of life in patients with terminal-stage disease]

Descriptive exploratory study

Describe preferences in decisions at the end of life of patients and families, and the underlying reasons that lead them to seek support

Outdated data: the legislation has changed after the publication of the article

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